Dysphagia and Esophagitis Gastrointestinal

and use of concurrent chemotherapy Feyer et al. 2011 . MASCCISOO and ASCO have created clinical practice guidelines for antiemetics with RINV and have devised an RT emetogenic risk stratifi cation, with high risk in those receiving TBI, moderate risk with RT to the upper abdo- men, low risk for cranial, craniospinal, head and neck, lower thorax, and pelvic RT, and minimal risk with extremity and breast RT Basch et al. 2011 ; Feyer et al. 2011 . Emetic prophylaxis should be per the chemotherapy- related anti- emetic schedule unless the risk of emesis is higher with RT Basch et al. 2011 ; Feyer et al. 2011 . Pediatric guidelines for RINV are lacking. Chap. 10 has a more extensive discussion of antiemetics in relation to chemotherapy- induced nausea and vomiting in children. MASCCISOO and ASCO guidelines both recommend prophylaxis with a 5-HT 3 receptor antagonist in the high- and moderate-risk groups with prophylactic dexamethasone in the high- risk group and optional dexamethasone in the moderate-risk group. MASCCISOO guidelines recommend prophylaxis or rescue with a 5-HT 3 receptor antagonist in the low-risk group while ASCO guidelines recommend no prophylaxis in this cohort. Finally, both guidelines advise res- cue only with either a 5-HT 3 receptor antagonist or dopamine antagonist in the minimal-risk group Basch et al. 2011 ; Feyer et al. 2011 . ASCO guidelines recommend a 5-HT 3 receptor antagonist prior to each fraction with 5 days of dexamethasone; MASCCISOO guidelines make no particular recommendation in regard to duration of prophylaxis Basch et al. 2011 ; Feyer et al. 2011 . Gastric protection should be consid- ered with repeated or prolonged dexamethasone therapy.

13.6.3 Enteritis

Abdominopelvic radiation can cause acute injury to the small bowel mucosa leading to enteritis GI mucositis with cramping, diarrhea, and malabsorptive symptoms, potentially exacer- bated by concomitant chemotherapy administra- tion Chopra and Bogart 2009 . Basic bowel care is recommended including maintenance of ade- quate hydration and consideration for possible lactose intolerance and bacterial pathogens Keefe et al. 2007 ; Peterson et al. 2011 . Symptoms of radiation-induced enteritis have traditionally been managed with moderate bowel rest, such as institution of a low-residue, low-fat and low-lactose diet. For severe diarrhea, anti- motility agents such as loperamide or atropine may be utilized. Due to the risk of bacterial pathogens, treatable causes such as Clostridium diffi cile should be ruled out. A recent systematic review by MASCCISOO suggests the prophy- lactic use of probiotics with Lactobacillus spp. and sulfasalazine, 500 mg twice daily, to prevent RT-induced enteritis for adult patients with pel- vic tumors Gibson et al. 2013 . The recommen- dation for sulfasalazine is specifi cally for patients receiving pelvic EBRT. Additionally the guidelines recommend octreotide in patients after HSCT with chemotherapy conditioning that fail loperamide for control of diarrhea Gibson et al. 2013 . Patients undergoing RT are not included in this recommendation. Agents that have not shown benefi t and should not be utilized include amifostine, 5-ASA and related compounds, and sucralfate Peterson et al. 2011 ; Gibson et al. 2013 . Pediatric data are lacking.

13.6.4 Proctitis

Adult patients receiving radiation for anal cancer are at risk for the development of radiation proc- titis which is usually self-limited and leads to softer or diarrhea-like stools, pain, a sense of rec- tal distension with cramping, urgency, increased frequency, and rarely bleeding Chopra and Bogart 2009 ; Michalski et al. 2010 . A potential example in pediatric patients could be perineal sarcoma; evidence is lacking. RT doses to the rectum 45 Gy increase the risk for proctitis Michalski et al. 2010 . Recent guidelines by MASCCISOO and ESMO suggest the use of IV intrarectal amifostine prior to RT as well as HBO and sucralfate enemas for the treatment of procti- tis and recommend against misoprostol supposi- tories Peterson et al. 2011 ; Gibson et al. 2013 .